Liverpool Urgent Treatment Centre

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. We assessed all quality statements from this key question. At our last assessment in November 2018, we rated this key question as requires improvement. At this assessment the rating has changed to good.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a clear mission statement across the service to provide a good quality service that was responsive to the needs of patients. Leaders were committed to evaluating and developing the quality of the service and they worked in partnership with relevant stakeholders to monitor and deliver its strategy.

The culture of the service was based on transparency, inclusion and engagement. The provider understood the challenges and needs of people and their communities and was working with partner agencies to support people effectively. Staff reported good teamwork, they were clear on the service function which was to work in the interests of patients by providing the best patient experience they could.

Leaders understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge, and experience to lead effectively. The provider had arrangements in place to ensure senior managers were contactable during the full operational period and staff we spoke with knew how to contact them.

The provider had clear escalation plans that could be brought into effect during the operational period when pressures and high demands were experienced by staff. All staff knew how to trigger escalation and how to report this to the management team.

Staff told us managers were visible, and open-door policies were in place for when they needed support. There were a number of ways in which staff could give feedback to senior managers. This included senior manager visits to the service, regular staff meetings and daily safety huddles where changes and staffing issues were discussed. We had feedback from staff members who told us that managers and leaders were compassionate and inclusive. However, we found that some staff felt senior managers had not listened when concerns about low staffing levels were raised.

Leaders we spoke with told us they fostered a positive culture where staff could speak up and their voice would be heard. Policies and procedures were in place to support staff and arrangements were available such as access to a Freedom to Speak up guardian.

We observed that staff and leaders acted with openness, honesty and transparency. We were told that leaders encouraged staff to raise concerns and promoted the value of doing so. However, we found that whilst the service was reporting high numbers of significant events, there was a lack of evidence to show that staff had been given feedback on the results of the actions taken by the provider. We found there were mixed feelings about how staff felt they were supported when speaking up about issues and concerns, how they would be investigated and if staff would be treated sensitively and confidentially.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for the service. Leaders acted to remove bias from practices to ensure equality of opportunity and experience for staff. Leaders supported staff who had protected equality characteristics, or those from excluded and marginalised groups. Policies were in place to prevent and address bullying and harassment.

We saw that there were opportunities for staff to give feedback on how the service operated. There were both formal and informal processes to support this. However, we did not find evidence that the views of staff on the operation of the service had been sought via a process that allowed for views to be collated, analysed and responded to.

There were clear and effective arrangements for governance, management and accountability. A clear management structure was in place with designated staff members who acted as leads for clinical and non-clinical areas. Staff roles, responsibilities and lines of accountability were clear.

We saw how information about risk, performance and outcomes were monitored and how change was discussed and implemented following feedback from people who used the service, staff and relevant stakeholders. Risk registers were in place across each of the divisions and departments monitored by the trust board senior leadership teams. There were monthly contract monitoring meetings taking place with local commissioners to monitor activity, productivity, KPI compliance, performance, incident management and quality standards.

Quality and operational information was used to improve performance. The provider monitored the performance of the service across key indicators and improvements were made to the service as required. The indicators covered areas such as waiting times, people who had left the service without being seen, patient demand and patient attendance. Where the service was not meeting the targets, the management team monitored this monthly and action plans were in place. The provider also had an audit management and tracking tool with a dashboard showing key quality assurance and governance indicators. The management team used this to monitor compliance, track performance, and take prompt action where improvements were required.

The service completed specific audits routinely via the trust wide audit system. These included for example, anti-microbial audits carried out in 2025, gaining 100% compliance for two audits undertaken. The service conducted local audits to gain assurance of adherence to specific processes or pathways. For example, pathway, triage audits and emergency resuscitation equipment audit.

Performance data, risk information, productivity information and response times were reviewed at team, divisional and trust board level. To review these systems the provider undertook an external quality assurance review commissioned by the trust board. The overall objective of the review was to provide assurance that systems and processes were in place to accurately report performance against the service KPI’s. The results of the review indicated its overall assurance was rated as high, especially for how performance was mapped up to the trust board level.

There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary. Staff were encouraged and supported to undertake mandatory training and development. However some staff reported difficulties in completing this due to time constraints.

A major incident/ business continuity plan was in place. Staff had been involved in emergency planning exercises, for mass casualty incidents and for managing people who had been exposed to hazardous materials.

The provider worked collaboratively and in partnership with relevant stakeholders, commissioners and partner agencies to support joint working and provide and develop effective services. The service shared information and learning with partners and collaborated for improvement.

The service had positive and collaborative relationships with external partners to build a shared understanding of challenges across the systems reviewing ways to improve and innovate services to meet patient needs. This included local emergency departments, local paediatric hospitals and ambulance services amongst others. Joint working opportunities and standard operating polices were in place to ensure patients were transferred across services safely. All services offered by the provider were on the national Directory of Services which was up to date. We were told there was transparency and openness with all stakeholders about the service performance.

The service demonstrated how they continually collaborated with other services operated by the provider and with external services to make improvements. For example, they were developing a Mental Health and Self-Harm Policy for Children and Young People in urgent treatment centres that supported escalation, safeguarding and referral onwards to specialist services.

The provider worked closely with the Integrated Care Board to monitor performance and on the development of the service. The provider responded to and implemented national and public health initiatives.

The provider ensured learning, improvement, and innovation by fostering a culture of continuous development and reflection across the organisation and at the service. The provider regularly assessed performance data, gathered feedback from service users and staff, and used this insight to drive changes. Training programs supported staff to reflect on practice so that learning could be shared with all members of the team. There were processes to ensure that learning was shared when there were incidents and action was taken to improve the service and prevent a reoccurrence. This included external partners and services. The provider worked collaboratively and in partnership with stakeholders to improve the experiences of people who used the service and those within the locality. For example, Urgent Treatment Centre/Walk in Centre Plan for Receiving Patients During Major Incidents and Mass Casualty Incidents. Leaders told us they maintained strong external relationships that supported improvement and innovation.